Complications of Severe Constipation

Severe constipation, acute or chronic, has to be treated promptly, otherwise complications mentioned below, may develop.

1. Bloating

Bloating and severe pain, usually in the lower left abdomen may result from gas, produced by normal intestinal bacteria that break down fiber in the stool stuck in the colon. The left side of the abdomen is distended and usually tender to touch. 

2. Lazy Colon

Lazy colon does not respond to presence of the stool in the colon and gastro-colic reflex that normally stimulate the bowel movement after food enters the stomach. Often even laxatives do not help. This poor colon activity may result from long term laxatives abuse, postponing bowel movements or prolonged bed rest. You often do not feel the urge to have a bowel movement. Lazy colon is a synonym for severe chronic constipation and does not mean a permanent colon impairment. You can achieve relief only by eliminating all possible causes of constipation and sticking with appropriate diet and active life style.

3. Fecal Impaction

In fecal impaction, a solid stool sticks in your colon and you can not expel it by your natural effort. It typically occurs in old bedridden patients, but can also affect other adults or children with chronic constipation or those taking opiates or methadone. A meal with a large amount of cereals without drinking enough fluid may also result in fecal impaction. In infants, rice cereals with milk could be the cause. Sensation of fullness or pain in the rectum, urge to defecate, abdominal discomfort, cramping, nausea and frequent urge to urinate are main symptoms. Clear stool may accidentally pass impacted stool; this is called paradoxical diarrhea. You may feel a hard lump when you press deeply upon the lower left part of your abdomen.

Sometimes you can remove the stool piece by piece using a finger, or a doctor can do so under local or general anesthesia. Forceful expelling hard stool is not recommended since your anus can tear. Water irrigation using a sigmoidoscope is sometimes necessary. Glycerin suppositories or phosphate or arachis oil enema may also be used. Stool softener, as docusate, may help pass the stool. If impaction is higher in the colon, an oral solution containing polyethylene glycol (as used in colonoscopypreparation) can be used carefully under doctor control. Rarely, operative removal of impacted stool is required.  Fiber laxatives, like metamucil, may be used as prevention of impaction (1). Read about foods that cause constipation.

4. Obstipation

Obstipation is severe constipation caused by intestinal obstruction, which may be acute or chronic, partial or complete. Constipation, abdominal distension, painful cramps and vomiting are main symptoms. Obstruction of the intestine may be caused by a polyp, cancer, scar tissue (adhesionsor strictures) developed after surgery or inflammation, volvulus (intestine twist upon itself – congenital defect found in infants), intussusception (telescoping, when one part of intestine slips into adjacent part; found in infants and young children), hernia, gallstones or foreign bodies. Certain diseases, like scleroderma, lupus or amyloidosis, can affect motility of the colonic wall. Ultrasound can detect excessive stool within the intestine. Obstipation has to be solved quickly by operation to prevent bowel perforation, bleeding or infection.

5. Rectal Prolapse

Rectal prolapse is protrusion of a part of the rectum through the anal opening during the bowel movement. It usually occurs in old people with chronic constipation who have week pelvic floor muscles and strain during the bowel movement. Full-thickness rectal prolapse usually causes constipation, while partial prolapse involving only the rectal lining does not.

Bulking laxatives or stool softeners may prevent aggravation of prolapse, but sometimes a surgery is necessary.

6. Rectocele

A rectocele, mostly occuring in women after menopause, means bulging of the rectum forward toward the vagina. It happens after heavy vaginal delivery or constant lifting of heavy loads. The stool may be trapped in the bulge. A doctor can detect this bulge during a vaginal and rectal examination.

Kegel exercises to strengthen muscles of pelvic floor may help in mild cases (2). If a rectocele protrudes through the vagina, surgery is usually necessary.

7. Anal Fissure

An anal fissure is a tear of the anal mucosa occuring during forced passage of large and hard stool. After the tear, you may feel severe pain lasting for several hours, and you may find blood on the stool or toilet tissue. Pain and bleeding during the bowel movements may persist for several weeks.

Treatment:

  • Warm sitz baths for 10-20 minutes few times a day sooth anal muscles
  • Stool softeners enable soft passage of the stool
  • Local analgesic creams relieve the pain
  • A tear usually heals completely in few weeks on its own, but sometimes surgical treatment is required.

Repeated injury of the anal sphincter by hard defecation may lead to patulous (widened, spreading) anus with diminished anal sphincter tone; a surgical repair is required in this case.

8. Chronic Hemorrhoids

Chronic hemorrhoids are common complication of chronic constipation. Treatment includes diet rich in fiber and fluid, physical activity, sitz baths, anti-hemorrhoidal and analgesic creams. Bluish hardened hemorrhoids with extreme anal pain and tenderness may result from thrombosed hemorrhoids, in which a blood clot form in the anal veins; an urgent surgical removal of a clot is required.

9. Non-Intestinal Complications

Urinary incontinence or infection or incomplete urine excretion are often connected with constipation where the rectum is full of hard stool.

Heavy straining may trigger heart attack or stroke. Holding breath and exerting raises the pressure in the chest cavity, preventing the blood from the veins to enter the heart. When the breath is released, the pressure within the chest drops and the blood having being trapped within the veins is quickly propelled through the heart, resulting in increased heart rate and blood pressure. Shortly thereafter, the heart rate reflexively slows down, what may trigger a heart attack in vulnerable persons. By the same mechanism, suddenly increased and then decreased blood flow in the brain may result in stroke or transient ischemic attack (TIA). Additionally, a blood clot may be dislodged from atherosclerotic brain arteries resulting in stroke. These are two causes of not so rare “toilet deaths” mostly occurring in old people with severe atherosclerosis. Squatting position during the bowel movement greatly reduces a need for straining.

References:

  1. Fecal impaction  (nlm.nih.gov)
  2. Kegel exercises  (mayoclinic.com)

Article reviewed by Dr. Greg. Last updated on April 12, 2011